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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 421700134
Report Date: 11/02/2023
Date Signed: 11/07/2023 09:49:58 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/07/2023 and conducted by Evaluator Francisca Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 17-CC-20230807161328
FACILITY NAME:GRACE LUTHERAN PRESCHOOLFACILITY NUMBER:
421700134
ADMINISTRATOR:KATHY LYNN LEDOUXFACILITY TYPE:
850
ADDRESS:420 EAST FESLERTELEPHONE:
(805) 922-5419
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:63CENSUS: 19DATE:
11/02/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Crystal CorkernTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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1.) Staff did not seek timely medical attention for child.
2.) Staff did not notify child's parents of injury.
INVESTIGATION FINDINGS:
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On 11/2/23, Licensing Program Analyst (LPA) Francisca Velazquez conducted an unannounced inspection of the Child Care Center (CCC) to deliver the finding with respect to the allegations noted above. LPA met with Crystal Corkern, Director of the CCC and explained the nature and purpose of the investigation. LPA toured the interior and exterior of the CCC. LPA notes 19 children are present at the time of the inspection, being supervised by 4 staff members and Director.

The allegation of staff did not seek timely medical attention for child was fully investigated by CCLD’s Investigation Bureau (IB). The IB investigation included observations, record reviews, interview with reporting party (RP) interviews with the Director, interviews with CCC staff as well as interviews of children in the CCC and interview with parent of a child enrolled in the CCC. IB investigation determined the allegation of staff did not seek timely medical attention for child is substantiated. According to the information obtained by IB, the incident occurred on 8/3/23 before 1600 hours, but S1 did not report the incident until 1715 hours.
CONT 9099-C and LIC 9099 D
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca VelazquezTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 17-CC-20230807161328
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GRACE LUTHERAN PRESCHOOL
FACILITY NUMBER: 421700134
VISIT DATE: 11/02/2023
NARRATIVE
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On 8/3/23 at 1600 hours, P2 observed C1 in the corner crying and S1 told P2 that C1 fell. At 1710 hours, parent of C1 arrived to pick up C1 and noticed C1’s arm was swollen, so parent took C1 to the hospital. Upon arrival to the hospital C1 appeared to have a left wrist fracture. After X-rays were conducted C1 was diagnosed with an acute fracture of distal radius and ulna which was 100% displaced. S1 did not inform management or parents of C1’s injury. IB found sufficient evidence to support neglect as S1 failed to report the incident and obtain medical attention for over an hour, therefore the case is closed with a substantiated finding.

The allegation of staff did not notify child’s parents of injury included record review, interview with Director and interview with complainant. According to the information obtained through the investigation, Director reported finding out about C1’s injury by the complainant who called to report C1’s injury and to gather details about how the injury occurred. Director disclosed not having knowledge of the injury as S1 had not reported the incident to Director. Director admitted to not knowing about the incident before parents of C1 informed Director. Interview with RP revealed both parents of C1 did not have knowledge of C1’s injury until C1 was picked up from the CCC. Additionally, complainant reported Director had to reach out to S1 to learn about the injury. The investigation found sufficient evidence to support the allegation of staff did not notify child’s parents of injury, therefore the case is closed with a substantiated finding.

Based on observation, record reviews and interviews, the preponderance of evidence standard has been met, therefore the above allegations noted above are found to be SUBSTANTIATED. California Code of Regulation, (Title 22 Division 12, 101226(a)(1) and Title 22 Division 12, 101226(b), are being cited on the attached LIC 9099 D).

A closing interview was conducted with Director. Director was provided and advised of Appeal Rights (LIC 9058). A copy of this report was reviewed and provided to the Licensee. LPA explained the facility's required plan of correction. Director was provided the Acknowledgement of Receipt (LIC 9224). Parents shall receive a copy of 9099, 9099C, and 9099D. Each parent/guardian shall sign and complete an LIC 9224 with copies maintained in each child's file. Every parent enrolling a new child in the facility shall receive a copy of the report and sign a LIC 9224 for the next twelve months. Director's signature at the bottom of this report acknowledges Director received the reports and understand their rights.

The Notice of Site Visit was also provided to the Director as required by H&S Code Section 1596.817. The Notice of Site Visit must remain posted for 30 days or a civil penalty of $100.00 may apply.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca VelazquezTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 17-CC-20230807161328
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: GRACE LUTHERAN PRESCHOOL
FACILITY NUMBER: 421700134
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2023
Section Cited
CCR
101226(b)
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101226 -Health-Related Services (b) The licensee shall make prompt arrangements for obtaining medical treatment for any child if necessary. This is an immediate risk to the health, safety, and personal rights to the children in care. This requirement was not met as evidenced:
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Director agrees to submit a written statement detailing how the CCC will ensure medical treatment is obtained for any child when needed. Director will submit proof that all CCC staff has been trained regarding Health related services. Written statement will be due by the end of business day on 11/3/23
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C1 sustained injury on 8/3/23 at around 1600 and S1 did not obtain medical treatment for C1's injury until parents picked up C1 and took C1 to receive medical treatment. This is an immediate risk to the health, safety and personal rights of children in care.
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via email to Francisca.Velazquez@dss.ca.gov
Type A
11/03/2023
Section Cited
CCR
101226(a)
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101226 -Health-Related Services (a) The licensee shall immediately notify the child's authorized representative if the child becomes ill or sustains an injury more serious than a minor cut or scratch... This requirement was not met as evidenced by:
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Director agrees to submit a written statement detailing how the CCC wil train staff on reporting requirements in regard to injuries sustained at the CCC, specifically regarding notifying parents of injured child. Written statement will be due by the end of business day on
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Interview with Director revealed that Director found out about C1's injury through parent of C1. Director acknowledge not knowing of this incident as S1 did not report this injury to the Director. This is an immediate risk to the health, safety and personal rights to children in care.
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11/3/23 via email to Francisca.Velazquez@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca VelazquezTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/07/2023 and conducted by Evaluator Francisca Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 17-CC-20230807161328

FACILITY NAME:GRACE LUTHERAN PRESCHOOLFACILITY NUMBER:
421700134
ADMINISTRATOR:KATHY LYNN LEDOUXFACILITY TYPE:
850
ADDRESS:420 EAST FESLERTELEPHONE:
(805) 922-5419
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:63CENSUS: 19DATE:
11/02/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Crystal CorkernTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
1.) Child sustained fractures while in care due to staff negligence.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/2/23, Licensing Program Analyst (LPA) Francisca Velazquez conducted an unannounced inspection of the Child Care Center (CCC) to deliver the finding with respect to the allegation noted above. LPA met with Crystal Corkern, Director of the CCC and explained the nature and purpose of the investigation. LPA toured the interior and exterior of the CCC. LPA notes 19 children are present at the time of the inspection, being supervised by 4 staff members and Director.

The allegation of child sustained fractures while in care due to staff neglligence was fully investigated by CCLD’s Investigation Bureau (IB). The IB investigation included observations, record reviews, interview with reporting party (RP) interviews with the Director, interviews with CCC staff as well as interviews of children in the CCC and interview with parent of a child enrolled in the CCC. IB investigation was unalbe to cooborate the allegation of child sustained fractures while in care due to staff negligence. There were no witnesses to the incident except for S1 who reported C1 fell while attempting to climb a bookshelf. CONT 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca VelazquezTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 17-CC-20230807161328
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GRACE LUTHERAN PRESCHOOL
FACILITY NUMBER: 421700134
VISIT DATE: 11/02/2023
NARRATIVE
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S1 attempted to stop C1 from climbing the bookshelf. There was insufficient evidence to support neglect as it was reported that S1 was present and attempted to stop C1, therefore this case is closed with an unsubstantiated finding.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

A Notice of Site Visit (LIC 9213) and Appeal Rights (LIC 9058) were provided to the Director, Crystal Corkern. The Notice of Site Visit must remain posted for 30 days or a civil penalty of $100.00 may apply.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca VelazquezTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5